Thomas Rutledge Ph.D.

The Healthy Journey

Why The Key Result of Bariatric Surgery Isn't Weight Loss

Changes in the person, not the bariatric procedure, mostly define the outcome.

Posted Sep 26, 2019

According to the most recent statistics from the American Society of Metabolic and Bariatric Surgery (ASMBS), an estimated 228,000 bariatric surgeries were performed in the U.S. in 2017. Although this number may sound large, it represents a tiny fraction (about 1%) of those eligible for bariatric surgeries based on their weight and health conditions. Weight loss is widely promoted as the primary purpose of bariatric surgeries.

In the public-at-large, for example, the emphasis on weight loss from bariatric surgeries is so great that these procedures are synonymously referred to as “weight loss surgeries.” Among people interested in bariatric surgery for themselves or a loved one, these procedures are chiefly advertised as being the most effective treatment for weight loss. Even in publications by ASMBS—a group with cutting edge knowledge regarding the many improvements commonly resulting from bariatric surgeries—success is primarily defined in the form of weight loss metrics such as “percent excess weight loss” (commonly abbreviated as %EWL).

Contrary to this prevailing perspective, however, weight loss and even improvements in weight-related health conditions are not the key ingredients to a successful bariatric surgery. To be clear, this is not to imply that weight loss and health changes are not important at all to the people receiving bariatric procedures, only that they are exaggerated by advertising and public opinion. The reason for highlighting this overemphasis on bariatric weight loss is twofold: 1) It distracts people from the bariatric outcomes that are even more important than weight loss. As we’ll see, improving these outcomes usually require efforts from the patient above and beyond the surgery; and 2) It reinforces the harmful tendency to equate a person’s success and self-worth with their weight, a tendency that is already practiced by many people struggling with their weight. No matter how well intended, defining bariatric surgery primarily by weight loss is counterproductive for many bariatric patients. Instead, most people entertaining bariatric surgery as a treatment option benefit from a better philosophy about these procedures to improve their individual outcomes. This post will: 1) Provide an outline for this better bariatric surgery philosophy; and 2) Describe a few of the many examples where an excessive focus on bariatric weight loss inadvertently sets people up for poor outcomes.

Image by TeroVesalainen from Pixabay
New perspectives=new results
Source: Image by TeroVesalainen from Pixabay

A New Philosophy for Bariatric Surgery

When you speak with people in the months and years following their bariatric surgeries, you routinely observe that their success is less the result of weight loss and more by changes in the following three areas: 1) Improved FEELINGS, including physical dimensions such as energy and endurance and psychological dimensions such as confidence and happiness; 2) Improved FUNCTION, particularly their ability to engage in the activities of greatest value to them personally (e.g., their ability to keep up with their children, not their time on a 6-minute walk test administered by their doctor); and 3) Improved FRATERNIZING in terms of better intimate, family, and friendly relationships, and other forms of social engagement.  In short, a better philosophy about bariatric surgery is that surgery represents an opportunity for personal transformation. The bariatric procedure itself is merely the first domino in a process that must include equivalent changes to a person’s head, emotions, and social and physical environments to fulfill its potential. Although one might naively believe that improvements in these three areas correlate closely with bariatric weight loss, in practice the relationship is moderate at best and inconsistent from person to person.

Harms of an Outdated Bariatric Philosophy

It is an invaluable practice to separate intentions from outcomes, for they routinely differ. The intentions behind the emphasis on bariatric weight loss are indisputably good, for example, yet this emphasis can contribute to a range of unintended harms. Here are just a few:

1. Weight loss alone has limited effects on happiness and depression, disappointing many patients led to expect big changes. More than 20 years of research studying changes in emotional health after bariatric surgeries shows that the average person enjoys only mild to modest improvements in their mood. For those who want improved emotional well-being in their post-bariatric life, they cannot depend on weight loss alone. Many will need to personally lead efforts to change their relationships, jobs, and lifestyles, for example, whereas others will need to improve their thinking habits—such as decreasing self-criticism, pessimism, and tendencies to talk themselves out of things.

2. The focus on weight loss causes many patients to overlook changes in their close relationships. Bariatric surgery has predictable effects on relationships for which would-be bariatric patients need to be prepared. Research on bariatric surgery shows what may seem likely a counterintuitive pattern with relationships: 1) those married before bariatric surgery have an increased risk of divorce after surgery; and 2) those single before bariatric surgery are more likely to get married after surgery. Distracted by the emphasis on bariatric weight loss as the goal, many patients are caught off guard by the dramatic social changes after their surgery – some of which are negative and very challenging – and aren’t able prevent or respond effectively to problems.

3. The focus on bariatric weight loss obscures the reality that the person is far more important than the surgery (or the surgeon) to success. In the initial days, weeks, and months following a bariatric surgery, the procedure radically alters eating behaviors and appetite mechanisms. However, the importance of the person soon catches up to and surpasses the importance of the procedure. The months following the bariatric surgery is when old habits begin to reemerge, complacency sets in, and progress begins to reverse unless the person has the mindset of being in the driver’s seat rather than the passenger’s seat of the bariatric process.  

4. The bariatric weight loss focus may contribute to increases rates of addiction and suicide reported in research. An unhealthy food-relationship is often present among those pursuing bariatric surgeries and the inability to use food as an emotional coping tool after bariatric surgery appears to be a factor involved in some turning to other forms of substance abuse. Similarly, when even bariatric weight loss does not produce the hoped-for feelings of self-worth or belonging, it may cause some to lose hope. Reducing the emphasis on weight loss as the solution while increasing the emphasis on steps to improve emotional management skills and mental health may be a better approach for many.

5. Lastly is the common but rarely discussed disparity between bariatric weight loss and self-image. Many objectively thinner and healthier patients maintain their self-images as fat, unattractive, and unwanted long after their bariatric procedures. These same patients typically think there must be something wrong with them, under the assumption that their weight loss should naturally change how they see themselves. In reality, the lagging self-image often won’t change on it’s own, requiring separate steps and strategies independent of weight loss.

With millions now living with or pursuing bariatric surgeries, a philosophy that empowers better long-term results while reducing the unintended harms of the traditional weight loss focus appears long overdue.